Homecare, Part 1: “Alone on the Train”

David Ponka, MD CM CCFP(EM) FCFP

August 29, 2017

I had a terrible dream last night. I was on a train with my family, but something
wasn’t right. The train starting going faster and faster. Gradually, people started
jumping off, but I wasn’t able to move. My wife and three daughters made it off, but
I rode off in the train alone. It wasn’t clear when it was going to stop.

When I woke up in a sweat, I realised why I had this dream. I have been thinking a
lot about the gaps we face to provide homecare to a population increasing in need.
As a result, these patients, mostly elderly, are institutionalized at high rates (1),
separated and isolated from their families and communities, often despite their will.
They must feel like I did in my dream: alone, powerless, and scared.

A lot has been written on the importance of homecare to meet the demographic changes
facing Canada. As each province has to reform its health system somewhat in ways to
meet these demands, the Federal Ministry has appropriately tied some cash transfers
to progress made on reforms, thereby setting homecare as a federal priority (2).

Implementation of this agenda has thus far been highly variable, despite the time
pressures at hand. In Ontario, responsibility for homecare has recently been transferred
to Local Health Integration Networks (LHINs) to address ongoing problems with coordination
of care. This has been controversial but has promise at least for one reason: LHINs
(and sub-LHINs especially) are by definition interested in linking patients and providers
geographically.

This is important. I currently have patients who drive an hour or more to see me,
a result of years of difficulty finding a family physician. Unfortunately, I cannot
return the favor as they age and need care at home. Thus, continuity of care is interrupted
in a dimension that we do not think about often enough in Canada, that of geographic
continuity, or the ability to provide service across geographic locations (clinic,
hospital, and home) (3). This is surprising, given that Canada is defined by geography.

When I moved my family to London, UK (to study medical geography), we were immediately
assigned a clinic within walking distance of our flat. Some may think this is too
prescriptive, but we could still choose from a number of providers within that clinic.
Certainly, the sheer density of providers in the UK makes this more attainable, but
there is no reason that patients in Canada should drive across the city for care.
Especially as they age and need services closer to home.

In Ottawa, we have run a number of models using Geographic Information Systems to
show that rates of home visits drop off markedly when a patient lives more than five
kilometers from their provider. That doesn’t sound like much does it? But considering
that we often do home visits first thing in the morning or after clinic in rush hour
traffic, those five kilometers may explain a lot. And because, with rare exceptions
(Community Health Centres in the province have a geographic mandate, perhaps explaining
in part their better outcomes), we may be driving in different directions during an
afternoon booked with home visits, those kilometers add up quickly.

We are trying to study this pattern provincially, knowing that even one home visit
by a physician makes it much more likely for patients who want to die at home to do
so (4). There are probably many other factors at play, but the role of geography cannot
be understated.

We are also interested in the role the physician’s home address may have in providing
home visits to their patients, but these data are much more difficult to obtain. (If
any readers are interested in how one may be able to study this, it would be great
to hear from you.)

For now, I have been asking more of my patients (from Hawkesbury, or Carleton Place,
or even Kanata—20 kilometers away) what they would want should they need home visits.
It hadn’t occurred to them that distance might be such a barrier. We talk about what
may be possible (Ottawa is getting a light rail next year, and that will help, but
it will still involve getting on a train), and what may lie ahead. Often, older patients
talk about wanting to be closer to loved ones. Some have moved away.

Perhaps Ian McWhnney inherently understood all this when he advised us to “share the
same habitat as [our] patients” (5). And perhaps the LHINs are listening too: it is
very rare for me to be referred a new patient who lives more than that magical five
kilometers away.